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              -  Home 
              -  Sickness Benefits for Railroad Employees 
              -  Instructions for Completing Forms 
              -                   Application for Sickness Benefits (Form SI-1a)              

## Topics

-  Introduction 
-  Qualification Requirements 
-  Amount and Duration of Benefits 
-  Eligibility Requirements 
-  Medical Statements 
-  Sick Pay and Supplemental Sickness Benefits 
-  Disqualifications 
-  Benefit Reductions 
-  Personal Injury Settlements 
-  Reconsideration and Waiver 
-  When Sickness Benefits are Taxable 
-  Instructions for Completing Forms    -  General Instructions 
  -  Important Informtion 
  -  Application for Sickness Benefits (Form SI-1a) 
  -  Statement of Sickness (Form SI-1b) 
  -  Statement of Authority to Act for Employee (Form SI-10) 
  -  Claim for Sickness Benefits (Form SI-3) 
-  Notices 
-  Checking Your Benefits by Telephone 
-  Important Reminders 

 

**Section A - Identifying Information**

**Items 1 - 6** are self-explanatory.

**Section B - Infirmity and Employment Information**

**Item 7** - is self-explanatory.

**Item 8** - Enter the date you last worked for your last railroad employer before you became sick and unable to work. For example, if you worked on 12/31 and became sick on 1/1, would enter 12/31 as the date last worked.

**Item 9 and 10** - are self-explanatory.

**Item 11** - Enter the title of your job. For example, "Road Brakeman."

**Item 12** - Enter the department of the railroad in which you work. For example, "Train and Engine Service."

**Item 13A-C** - Complete this item if you worked for a non-railroad employer or were self-employed after the last day you worked for a railroad employer.
                        - Item 13A  - Enter the name of the company for which you worked most recently. For example, "Acme Accounting."
                        - Item 13B  - Enter the title of your job. For example, "Accountant."
                        - Item 13C  - Enter the date you last worked outside the railroad industry before you became sick and unable to work. For example, if you last worked on 12/31 and became sick on 1/1, you would enter 12/31 as the date last worked.

**Section C - Accident and Insurance Information**

**Item 14 **is self-explanatory.

**Item 15** - Check "Yes"if you filed or expect to file a lawsuit or claim against any person or company for personal injury.

**Item 15A **is self-explanatory.

**Item 15B** - Enter the location where your injury or illness occurred. For example, "Hwy 51/County Rd 12, Toledo, Ohio."

**Item 15C** - Check "Yes"if you were injured in a automobile accident.

**Item 15D** - If you checked "Yes"in Item 15c, complete the following items about all the vehicles involved in the accident, other than your own.

**Owner of Car **- Enter the complete name and address of the owner of the other vehicle involved in the accident.

**Driver **- Enter the complete name and address of the driver of the other car or vehicle involved in the accident. If more than one other vehicle was involved, give information for all vehicles on a separate sheet of paper.

**Insurance Company** - Enter the complete name and address of the insurance company of the owner of the other vehicle involved in the accident.

**Policy Information** - Enter the policy number of the insurance policy held by the owner of the other vehicle and the claim number assigned by the insurance company, if you know it.

**Section D - Claim for Sickness Benefits Information**

Your first sickness benefit claim is Items 16 through 20 on your SI-1a, Application for Sickness Benefits. After your application and claim have been received and processed, your next sickness claim will be mailed to you.

**Item 16** - is self-explanatory.

**Item 17** - Check "Yes" if you want to claim every day from the date you entered in Item 16 through the current date as a day of sickness. Check "No"if you do not wish to claim every day. Remember that you cannot claim benefits for any day on which you worked or otherwise earned wages, holiday pay, vacation pay, sick pay (excluding supplemental sickness benefits) or other pay. This includes pay from full-time and part-time work in either railroad or nonrailroad employment, and from self-employment. You may claim rest days on which you were sick or injured and for which you do not receive pay from your employer.

**Item 18** - If you checked "No" in Item 17, enter the dates that you do not wish to claim.

**Item 19 **- If you have recovered from your infirmity and have returned to work, enter the date you returned to work. However, if you worked one or more days, but then continued to be unable to work, do not enter a date in this item. For example, if you attempted to return to work but found that you were not able to continue working, indicate the days you worked and received wages in Item 18, but do not enter a date in Item 19.

**Item 20A-C** - Each item must be checked "Yes" or "No" to indicate the type of payments, if any, that you have received or will receive for days in the claim period. Also furnish the dates and/or other information requested about the payment. The types of payments are explained below.
                        - Wages -  Payments that you receive from your railroad employer, from a nonrailroad employer, or your own business for services you performed. Benefits are not payable for any day for which you receive wages.     Regular Wages -  Pay for time worked, including full-time and part-time work.     Vacation Pay -  Pay for scheduled or assigned vacation days. Vacation pay does not include "pay in lieu of vacation."If you don't know if the payment you received was "pay in lieu of vacation,"check with your payroll office before completing this item.     Holiday Pay -  Pay from your employer for a holiday.     Military Reservist Pay -  Wages paid to you by the Federal Government based on your military service.     Wage Continuation Pay -  Salary or wages paid by your railroad employer when you have been injured on-duty. The purpose of the payments is to continue your wage or salary, not to supplement RRB benefits. The payments are subject to normal payroll deductions.     Earnings from Self-Employment  - Payment for services performed.     Sick Pay from Your Employer  - A continuation of all or part of your wages while you are unable to work. The term "Sick Pay"does not include supplemental sickness benefits.  Click here for an explanation of supplemental sickness benefits .  	 
                        - Governmental Payments  - Annuities or other payments made to you by a county, city, state or Federal Government. If you are receiving a governmental payment, check the appropriate box and give the beginning date, the gross amount and the frequency of the payment. For an explanation of how governmental payments affect the payment of sickness benefits by the RRB, see the section  Benefit Reductions .     Sickness or Unemployment Benefits Under Any Other Law  - Benefits paid to you on account of sickness or unemployment by a county, city or state government, or by another Federal agency.     Social Security Benefits  - Benefits paid to you by the Social Security Administration, excluding supplemental security income payments (SSI).     Railroad Retirement or Disability Annuity  - Monthly payments made to you by the RRB based on your age and railroad service or on disability. An RRB annuity under the Railroad Retirement Act is not the same as RRB sickness benefits.     Military Retirement Pay  - Retainer pay, an annuity, or pension paid to you by the Federal Government based on your military service.     Worker's Compensation  - Disability payments made to you under a state law when you have been injured on the job.     Retirement Payments Under Another Law  - An annuity or pension paid to you by a county, city, state or Federal Government.  	 
                        - Other Payments  - If you are receiving some type of other payment, check the appropriate box and give the date of the payment and who made payment to you.     Settlement or Damages for Personal Injury  - A payment received as a result of a judgment or the settlement of a personal-injury claim against your railroad employer or another party that you held liable for your injury or illness.     Advances  - A payment received in anticipation of a settlement of a personal injury claim against your railroad employer.     Separation Allowance (Buyout, Severance Pay)  - A payment received when you resign in return for a specified sum of money. The payments are also referred to as "buyouts" or "severance pay." Payment may be made in a lump sum or installments in return for your resignation.

**Item 21** is self-explanatory.

**SECTION E - Direct Deposit Information**

**Item 22 **- The Department of the Treasury (Treasury) requires all federal benefit payments to be made electronically. You will need to choose an electronic payment option. You can choose to have your payments made by Direct Deposit to a bank, savings and loan, credit union account or other financial institution or to a Direct Express Debit Mastercard. Both options save money by eliminating the need to print and mail checks.

An electronic payment has many advantages. Payments are generally available 2 or 5 days sooner than payment by check. You do not have to worry about a check being lost, stolen or misplaced, and you can be away from home without the worry of a check sitting unprotected in your mailbox. There is no need to wait for mail delivery of a check or to make a special trip to your financial institution.

To provide the information we need to correctly deposit your benefit payments, attach a voided personal check to your application or call your financial institution for the information you need to complete item 22A-E.

If you change financial institutions or your account while claiming benefits, be sure to give the RRB information to establish Direct Deposit to your new account. Do not close your old account until you receive the first RRB payment in your new account.

If you do not have an account at a financial institution or you prefer to receive your benefit payments on a prepaid debit card, you can call 1-888-544-6347 or visit www.GoDirect.org  for information about enrolling in the Direct Express program.

**Electronic Payment Waiver Conditions**

Treasury will allow benefit payments to be paid via paper check to individuals who:
                        - were born before May 1, 1921,
                        - have a mental impairment and do not have a representative payee,
                        - live in a remote area of the country that lacks infrastructure to support electronic financial transactions, or
                        - had a Direct Express Debit Mastercard that was suspended or cancelled.

You will need to contact Treasury directly at 1-800-333-1795 to apply for a waiver.

**SECTION F - Certification and Signature -**

**Item 23** - By signing and dating this item you certify that the information contained on the form is true, correct, and complete.

If the sick or injured employee is unable to sign in Item 23, the person completing the application should sign in Item 23, and complete Form SI-10, Statement of Authority to Act for Employee

   

**‹** Important Informtion
Up
Statement of Sickness (Form SI-1b) **›**

   

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								Last updated: 07/12/2017